Nokea
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.
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Which response by the nurse is most appropriate?
- A. Clipping the hair is hospital policy.'
- B. This method is better for you.'
- C. Shaving the head causes microscopic cuts, resulting in risk for infection.'
- D. Surgery could be postponed if bleeding from the scalp occurs.'
Correct Answer: C
Rationale: Clipping avoids microscopic cuts from shaving, reducing infection risk, which is critical for craniotomy.
The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering?
- A. Thiamine (vitamin B6) and librium, a benzodiazepine.
- B. Dilantin, an anticonvulsant, and Feosol, an iron preparation.
- C. Methadone, a synthetic narcotic, and Depakote, a mood stabilizer.
- D. Mannitol, an osmotic diuretic, and Ritalin, a stimulant.
Correct Answer: A
Rationale: Delirium tremens requires thiamine (vitamin B1, not B6) to prevent Wernicke’s encephalopathy and benzodiazepines like Librium (A) to manage withdrawal symptoms. Other options are unrelated to delirium tremens management.
The client with a history of migraine headaches comes to the emergency department complaining of a migraine headache. Which collaborative treatment should the nurse anticipate?
- A. Administer an injection of sumatriptan (Imitrex), a triptan.
- B. Prepare for a computed tomography (CT) of the head.
- C. Place the client in a quiet room with the lights off.
- D. Administer propranolol (Inderal), a beta blocker.
Correct Answer: A
Rationale: Sumatriptan (A) is a first-line treatment for acute migraines. CT (B) is for atypical cases, quiet room (C) is supportive, and propranolol (D) is for prophylaxis.
The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson’s Disease. Which priority intervention should the nurse implement?
- A. Keep the bed low and call light in reach.
- B. Provide a regular diet of three (3) meals per day.
- C. Obtain an order for home health to see the client.
- D. Perform the Braden scale skin assessment.
Correct Answer: A
Rationale: Parkinson’s increases fall risk due to bradykinesia and rigidity. Keeping the bed low and call light in reach (A) prioritizes safety. Diet (B), home health (C), and skin assessment (D) are secondary.